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Ethical Dilemma Immunisations

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Highlight an ethical dilemma within your area of practice. Critically discuss this in relation to ethical principles for practice.

There are many ethical issues and dilemmas which can arise in Public Health practice. Ethics is concerned with morals, duties and values (Seedhouse, 2008). Most interventions in public health are targeted at improving health and inequalities. The ideology of good health as the ultimate goal may lead to the lack of acceptance that health means different things to different people (Hubeley & Copeman, 2008). One ethical dilemma the author has encountered in practice as a student health visitor is parent’s who refuse to immunise their children. This has many ethical implication for practice.

Immunisations are essential in protecting individuals and the community from serious diseases. The Department of Health (2005; 2006; 2009) offers clear, evidence-based information about different diseases, the possible side effects of immunisation and the current immunisation schedule which is available to all children. All babies are born with a little natural immunity to disease, but immunisation can offer additional protection against certain serious illnesses (GB: DH, 2006). Immunisation has caused dramatic improvements in health. Because of immunisation, diseases such as diphtheria, tetanus and measles, which used to be major causes of ill health now have much lower incidences (NICE, 2009). The Healthy Child programme (GB: DH, 2009) views immunisation as a national priority and aims to see an increase in the proportion of children who complete the immunisation schedule by the recommended ages. Immunisation of children is not compulsory in the UK and parents (with parental responsibility) can decide whether or not to have their child immunised. Despite the evidence that vaccinations protect children against a range of serious illnesses many parents still decide to opt not to immunise their child (GB: DH, 2006). There are several reasons why they may do this; such as the fear of side effects, for example pain from the actual injection or the belief in the unproven link between the MMR vaccine and autism. Some parents hold belief in the use of alternative protection such as homeopathy or herd immunity. Herd immunity (or community immunity) describes a form of immunity that occurs when a large proportion of the population has been immunised and provides a measure of protection for individuals who have not been immunised. Religious or cultural beliefs may be another reason for refusing to enter into the immunisation schedule (Simpson, Lenton & Randall, 2005).

Health visitors have the lead role in the delivery of the Healthy Child programme (GB: DH, 2009). They are responsible for working with parents and families to ensure children under 5 years are offered immunisations as specified in the immunisation schedule. For parents who refuse to immunise their child the health visitor is responsible for ensuring that these individuals are given appropriate health promotion to enable the parents to make an informed choice.

Within their scope of practice, all health visitors are bound by certain ethical principles. There are four bioethics, including autonomy, beneficence, nonmaleficence and justice. Autonomy is concerned with the rights of the individual and the importance of allowing people to make their own decisions. The central concept to autonomy is informed consent (Beauchamp & Childress 1994). Simpson, Lenton & Randall (2005) suggest that knowledge deficit can often the greatest barrier influencing a parent's willingness to vaccinate. In relation to children it is the parents’ responsibility and right to make the decisions about immunisations. By disempowering an individual’s autonomy this will lead to increased resistance to health related change (Naidoo & Wills, 2011). The second principle is beneficence and this relates to taking action and promoting good. This considers the best interest of the child, in which the benefits of the intervention must outweigh the potential harms caused by the intervention (Master, 2009, p.93). For example the benefits of immunisation must be greater than the potential side effects of the vaccination. Nonmaleficence relates to ‘do no harm’ and refraining from actions that might harm others (Beauchamp & Childress 1994). Regarding the potential to harm, some may be concerned about the invasiveness of a needle in a child and the pain it might cause. Some may also argue that by causing pain or potential harmful side effects to a perfectly healthy individual, is violating the principle of nonmaleficence (Baines, 2008). Justice, means giving each person or group what they are due. It can be measured in terms of fairness and equality (Masters, 2009, p.93). The vaccination schedule is deemed part of the universal pathway in the HCP which makes it available to all children in the UK.

The Stewardship model is beneficial to public health as it highlights appropriate aims and constraints. An acceptable aim is that of protecting and promoting health of children. However it states that in achieving this goal professionals must not attempt to coerce individuals into making decisions or restrict their freedom of choice unnecessarily (Nuffield Council on Bioethics, 2007). Deontology is another theory which supports this statement. Deontological theory looks at inputs rather than outcomes and judges the morality of an action based on an individual’s duty and moral obligation (Seedhouse, 2008). Duty deontology relates to a set of rules or code of conduct which defines acceptable and not-acceptable actions (Masters, 2009, p.90). Health visitors are bound by The NMC code of professional conduct: standards for conduct, performance and ethics. This code tries to ensure consistency between what professionals preach and their own actions (NMC, 2008).

In summary, childhood immunisation in the UK is not compulsory therefore it is the parents’ decisions whether or not to immunise their child. Their decision will be made in accordance with what they feel is in their child's best interests. It is the role of the health visitor to ensure adequate health promotion in order to allow parents to make an informed decision. The health visitor must take into account relevant ethical principles and base their professional opinion on the best available evidence.

References
Baines, P. (2008). Medical ethics for children: Applying the four principles to paediatrics. Journal of Medical Ethics, 34(3), 141–145.

Beauchamp, T. L., & Childress, J. F. (1994). Principles of biomedical ethics (4th ed.). New York: Oxford University Press.

GB: Department of Health (2005) Vaccination services: reducing inequalities in uptake [Online]. Available at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4105349 (Accessed: 10 January 2013).

GB: Department of Health (2006) Immunisation against infectious disease - the Green book [Online]. Available at: http://immunisation.dh.gov.uk/gb-complete-current-edition/ (Accessed: 10 January 2013).

GB: Department of Health (2009a) Healthy lives, brighter futures: the strategy for children and young people's health [Online]. Available at: https://www.education.gov.uk/publications/eOrderingDownload/285376a.pdf (Accessed: 10 January 2013).

GB: Department of Health (2009b) Securing better health for children and young people through world class commissioning: a guide to support delivery of healthy lives, brighter futures – the strategy for children and young people's health [Online]. Available at: https://www.education.gov.uk/publications/eOrderingDownload/285374a.pdf (Accessed 10 January 2013).

Hubley, J. and Copeman, J. (2008) Practical health promotion. Cambridge: Polity press.

Masters, K. (2009) Role development: In professional practice (2nd ed) London: Jones & Bartlett publishers.

Naidoo, J. and Wills, J. (2011) Developing practice for public health and health promotion. (3rd ed) Edinburgh: Bailliere Tindall.

NICE (2009) Reducing differences in the uptake of immunisations. Available at: http://publications.nice.org.uk/reducing-differences-in-the-uptake-of-immunisations-ph21/appendix-e-supporting-documents (Accessed 10 January 2013).

Nuffield Council on Bioethics (2007) Public Health: Ethical Issues. London: Nuffield Council on Bioethics.

Nursing and Midwifery Council (NMC) (2008) The code of professional conduct: standards for conduct, performance and ethics [Online]. Available at: http://www.nmc-uk.org/Documents/Standards/nmcTheCodeStandardsofConductPerformanceAndEthicsForNursesAndMidwives_LargePrintVersion.PDF (Accessed 19 January 2013).

Seedhouse, D. (2008) Ethics: the heart of health care. (3rd ed) Chichester: Wiley Blackwell.

Simpson, N., Lenton, S. and Randall, R. (2005) Parental refusal to have children immunised: extent and reasons. BMJ 310, (8) pp. 225-227

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